Some people have raised the issue of what defines mental illness, which is made clear in my book, Mental Illness Defined: Continuums, Regulation And Defense (https://bradbowinsbooks.com/mental-illness-defined/). Besides not aligning with the true nature of psychopathology, discrete diagnoses are less humanistic than a continuous characterization, whereby mental health problems range from normal to extreme levels. Take personality disorders, where in clinical practice there is an us versus them orientation. My continuous model of personality disorders views these problems as extreme and enduring expressions of common psychological defense patterns. For instance, avoidance is a normal survival defense when applied to dangerous agents, but when it occurs repeatedly in response to agents offering reward potential it is highly dysfunctional—avoidant personality disorder. We all engage in avoidance but it is the degree that counts, so the client and therapist are not all that different. The same applies to psychosis where based on a continuous model psychotic level cognitions represent the extreme range of thought content, thought form, and sensory perceptual experiences. We all experience psychotic level cognitions during sleep when dreaming, but with psychosis they occur repeatedly in the conscious and awake state, due (from my perspective) to impaired regulation over psychotic level cognitions. Hence, a value of my continuous model of mental illness (aside from aligning with scientific research and not pharmaceutical marketing needs plus our preference for discrete entities to simplify information process) is that it is much more humanistic!
The coronavirus outbreak arose in late 2019 in China and spread in 2020. Spreading faster than the virus has been anxiety, panic, and fear-based responses. Consequently, every day sees a new rule or change in policy, even when such an immediate reaction is not warranted. Fear is an evolved emotional response occurring when threat or danger is perceived, motivating adaptive responses. Human intelligence has intensified threat and danger related thoughts, amplifying the emotional responses. Worsening the situation is contagion, and I am not referring to biological spread of the virus. If we see another person reacting with fear it triggers a feeling of fear: there must be a threat because that person is reacting with fear. Our social evolution has left us vulnerable to contagion.
To this point in time, fear and its amplification—anxiety—appears to have taken a greater toll on people overall than has the virus. As a psychiatrist, I have noted intense anxiety not only in patients but those I know and observe outside of my practice. Many people fully retreat avoiding walking in areas largely devoid of people, further enhancing the perception of threat and danger. Undoubtedly, lower mood and even depression is on the rise related to the extreme isolation and anxiety. Hence, the mental health impact due to the spread of fear and anxiety has outstripped the impact of the virus! Now some might respond that the virus is killing people. Yes, but what the early peer-reviewed evidence indicates is that most of these people are elderly with significant medical illness, a segment of the population that is highly vulnerable to severe outcomes from upper respiratory tract infections. My mother contracted such an illness while in a nursing home and passed away from it, although the underlying medical illnesses were really what took her. These unfortunate individuals are always vulnerable to upper respiratory illnesses such as from viruses and bacteria.
A horrible consequence of this excessive anxiety and even panic response, whipped up by traditional and social media, is that rational thought processes, planning, and responses are sacrificed. In crisis circumstances, it is prudent to take a look at the relevant pluses and minuses, and act accordingly. Covid 19 to date primarily takes the elderly and ill; it is not equivalent to the swine flu of 1918 that was killing young and healthy individuals, nor is it turning people into zombies. Given this apparent reality, a logical reasoned course would have been to protect those vulnerable from the outset, such as screening anyone who has contact with a physically vulnerable person, and ensuring that only screened individuals interact with them. Instead the response has generally been irrational and fear-based, such as focusing on extensive isolation of those not that vulnerable to serious outcomes, with day-to-day changes in policies and rules as opposed to a few days to a week to adapt. This reactionary process only serves to ramp up fear, and lacks sense. For example, blanket one size fits all approaches such as treating flights from all destinations, even those with no reported cases, as a major threat while ignoring train and bus travel. Also, discouraging people to get out and walk in areas that are not congested, although few areas are crowded nowadays. Walking and maintaining a reasonable distance from others has an extremely low chance of spreading the virus, and the vast majority of those able to walk are not that vulnerable to serious consequences. With the mental health benefits of walking, being active, and seeing others enjoying this experience anxiety is countered. In other words, the minuses are low and the pluses high.
My suggestion as a psychiatrist, and also someone who has engaged in adventure activities such as backcountry skiing and scuba diving, is to resist the temptation to react with anxiety and panic. Counter the negative threat and danger perceptions, and weigh in the pluses and minuses of different courses of action. Also, appreciate the contagion impact, and realize that just because someone is reacting with fear and/or panic it does not mean there is a threat. Maybe in our ancestral hunting-gathering group history a fear response indicated a predator, but not now. Applying humor which is a mature defense consisting of placing a lighter spin on things can be a major asset in these heavy times. A humorous anecdote comes from a person I know who works in a newsroom, where a sign indicates, “Report every story as if it’s World War III.” The newsroom staff are getting so sick and tired of having to report the WWIII coronavirus narrative that they are hoping for a murder, stabbing, or cat stuck in a tree, just for a break from the repetition! An additional and easy way to counter the escalating fear and even panic, is to absorb yourself in a positive focus as the absorption helps negativity recede. Who knows, when online video watching is exhausted maybe picking up a book and reading. Also, resist media exposure as it is designed to ramp up fear responses!
Mental illness accounts for approximately half of all illnesses, but receives a fraction of the funding that physical illness does. In addition, treatment options are limited in their effectiveness and mental health in the general population is not ideal. Hence, there is a great need for beneficial and cost-effective interventions, with the situation dire in third world countries and even first world countries with unevenly spread mental health resources. But what might qualify as an option?
The answer is activity, particularly appealing given how natural and positive it is! In the realm of physical health physical activity is well established, but the notion of activity for mental health is still lacking. Interestingly, activity plays a much greater role in mental health than physical health, due to how for the latter it is really all about physical activity, while for mental health diverse types of activity play a role. As a psychiatrist treating a wide-range of conditions, I have seen first-hand the benefit of activity and routinely apply it to clients. Furthermore, I practice behavioral activation treatment (BAT), an intervention that is at least as effective as medication for severe depression. Furthermore, in my own life I have been highly active noting the benefits for mental health. This background and experience led me to research the spectrum of activity to reveal the evidence and uncover the reasons for why activity is so beneficial.
The resulting book, Activity For Mental Health(Academic Press) explores activity in general, and specific forms of activity—physical, social, nature, cognitive, art/hobby, and music. Two key reasons for why activity in general characterizes mental health are requirements derived from human evolution and the value of absorption in positivity. In contrast to our tree-dwelling higher primate relatives, humans had to be active walking about in search of food, water, safe resting sites, and other valuable resources. Consider our two-legged (bipedal) form of motion and how difficult this would be for chimpanzees, orangutans, and gorillas. These primates actually do quite fine in limited spaces, without the physical and mental costs that humans incur. In other words, we evolved to be active and this is expressed in the requirements for health. Regarding a positive focus, negative distractions are ever present and weigh us down psychologically. Absorbing oneself in a positive focus, such as that inherent in activity, removes a person from negativity fostering positive mental health. Absorption in positive foci represents a form of adaptive dissociation.
Beyond activity in general benefiting mental health, physical, social, nature, cognitive, art/hobby, and music activity each have an impact. In this day and age of “evidence-based” interventions, it is important to establish whether or not and to what extent the various forms of activity both treat mental illness and advance mental health in the general population. On a 1-5 scale with 1 the highest level, the evidence does not fall below 3 and is typically in the 1-2 range. The impact and reasons for why each form of activity is beneficial for mental health in brief consists of:
Various forms of research conclusively demonstrate that physical activity advances mental health. Improved physical self-perspectives and associated changes in self-concept appear to play a significant role in the psychological benefit. At a biological level, physical activity does appear to increase blood flow to the brain and neurogenesis meaning the growth and survival of neurons.
Humans evolved in hunting-gathering groups instilling a social brain, in contrast to tigers for instance that are quite fine on their own. We require social contact and in a world that is becoming more and more socially fragmented, isolation and loneliness contribute to mental illness. It turns out that the impact is greater for loneliness than isolation per se. With social and emotional support, mental health is advanced.
Given the beauty and serenity of natural settings it “naturally” follows that nature is beneficial for mental health, but certain safety related issues actually influence this outcome. The evidence is strong that nature activity can enhance mental health, even though the role of physical and social activity in nature has to be teased out. Regarding why nature activity seems to work, it induces relaxation responses thereby reducing stress responses. Several very interesting features of natural settings seem to align with how the brain is structured to achieve this outcome.
Although it would seem that mental activity enhances mental health in terms of mood and the like, very little research focuses on this, with the vast majority addressing the impact of cognitive activity on cognitive functioning, such as with dementia. The intriguing role of so-called negative symptoms is explored revealing the powerful impact on mental health and illness. One outcome that appears clear is cognitive activity predicting cognitive health and not the reverse. Pertaining to mental illness such as dementia the benefit is greatest in the early phases.
I note that few people have a real hobby while many can benefit from acquiring one. Research backs up this perspective demonstrating how such activity both treats mental illness and advances mental health in the general population. This outcome arises from diverse studies conducted in many regions of the world. Several psychological benefits including empowerment and motivation flow from art/hobby activity.
This form of activity might seem to fit into the art/hobby category, but it is very distinct. The history of music and mental health is entertaining with the good, bad, and ugly all well represented. Ultimately, it appears all good based on how music activity resonates with emotions due to amazing similarities. In addition, music appears to activate and stimulate many brain regions. The evidence for music activity enhancing mental health is very strong, and it appears to have a profoundly positive impact on elderly people.
Consistent with my clinical work, I cover how behavioral activation treatment works to reveal the power of behavioral activation. However, the focus is on informal activity to treat mental illness and improve mental health in the general population. Activity including the specific forms of physical, social, nature, cognitive, art/hobby, and music, represents a robust, cost-effective, and easily accessible mental health intervention. Treat yourself to activity therapy in the ways discussed, and expand the degree of involvement and diversity of options to the benefit of your mental health.
See the Books section of this website for more information and links to sellers.
The major diagnostic systems for mental illness, namely the Diagnostic and Statistical Manual of Mental Disorders (DSM) associated with the American Psychiatric Association and International Classification of Diseases (ICD) linked to the World Health Organization emphasize discrete conditions, such as Major Depression and Persistent Depressive Disorder in the case of depression, and Generalized Anxiety Disorder and Panic Disorder for anxiety. Currently there is DSM-5 and ICD-10. These discrete conditions sound very good and are appealing, but totally inaccurate! This issue is addressed in my book, Defining Mental Illness: Continuums, Regulation, and Defense. Nature tends to be organized dimensionally, with truly discrete entities the exception, likely derived from trait variation related to natural selection. Due to this reality I proposed the Continuum Principle: Natural phenomena tend to occur on a continuum, and any instance of hypothesized discreteness requires unassailable proof. Evidence for discrete mental illness conditions does not even come close to this standard. A continuous organization captures the true nature of these conditions. The illusion of discreteness can arise as an emergent property of increasing severity, as with melancholic depression representing the most extreme end of the depression continuum. In a similar fashion extreme anxiety involves the fight, flight, freeze response producing a panic attack. Triggering circumstances can also create this illusion, such as with winter stimuli intensifying behavioral inhibition and reducing behavioral activation triggering depression, instead of representing the discrete condition of Seasonal Affective Disorder (SAD)—In DSM-5 this condition has been shifted to depression with seasonal pattern. Likewise, social circumstances combined with personality issues such as introversion and low self-confidence can trigger social anxiety.
Reading this some will get it, while others will think that this does not feel right, the latter reaction highlighting how we prefer discrete conditions because this approach simplifies information processing. We think in terms of good and bad people, homosexual and heterosexual, instead of gradients. To a large extent the major diagnostic systems for mental illness derive from how we prefer to see things, a very unscientific occurrence. Then there is the dark side of how pharmaceutical companies can market products easier to discrete conditions than continuums. In 2010 antipsychotics and antidepressants were in the “Top 5” bestsellers generating $16.9 billion and $16.1 billion, respectively, in sales, aided by the sellout of academic psychiatry to big pharma! Essentially, psychiatry became a captured discipline beholden to the pharmaceutical industry. Now you might wonder how this process occurs? Academic psychiatrists dealing with medications, as opposed to psychotherapy, rely heavily on pharmaceutical companies for research funding. These psychiatrists ensure that they are on committees determining the criteria for supposed discrete diagnosis. Typically, 100% of those on the Mood Disorders and Psychotic Illnesses sub-committees have links to the pharmaceutical industry. Naturally they are going to support discrete conditions, and certainly when they align with our natural tendency to see discrete entities.
This problem of the pharmaceutical industry capturing psychiatry and ensuring discrete conditions arguably began with Dr. Donald Klein, who in 1964 proposed panic as a discrete condition. He was funded at the time by Geigy and Smith & Kline & French. Due largely to his influence on the DSM-III Anxiety and Dissociative Disorders sub-committee, Panic Disorder became a discrete condition in DSM-III (1980). Previously in DSM-II panic was seen as an extreme expression of anxiety, anxiety neurosis, “characterized by anxious over-concern extending to panic, and frequently associated with somatic symptoms.” In 1981 Upjohn marketed Xanax (alprazolam) for the new discrete condition of Panic Disorder, despite its own research showing little support for a separate condition. Insiders referred to the “condition” as the “Upjohn Illness.” Xanax was a blockbuster seller. 35 years later with DSM-5 the same problem is playing out, but interestingly big pharm appears to be distancing itself from psychiatry given that there are no new products that are working out, despite the inherent biases within the system. This outcome is not surprising when a discipline is captured and removed from real science focused on true outcomes!
Accurately defining mental illness is crucial for treatment providers and researchers, because it fosters a comprehensive understanding and optimizes therapeutic interventions. In addition, it frees psychopathology from political and financial influences that weaken its scientific integrity.
In combination, continuums, regulation, and defense, robustly define mental illness.
Continuums: Psychopathology embodied by major diagnostic systems (DSM and ICD) emphasizes discrete conditions, in line with our psychological preference for discreteness. However, nature almost universally gravitates to continuums. Naturally occurring mental illness continuums are identified, based on neuroscience and other relevant data.
Regulation: Despite how biological systems rely on regulation, it is largely neglected when it comes to mental illness. Psychopathology frequently arises from impaired regulation, fostering a shift from milder expressions on continuums to extreme manifestations. A diverse collection of therapeutic techniques, under the umbrella of cognitive regulatory control therapies, is presented that restore effective regulation.
Defense: The surprising role of psychological defense, understood in terms of compensation for stressors, is described for the various mental illness continuums, and techniques are provided to augment healthy defensive functioning.
The model of psychopathology proposed aligns with its natural organization, thereby placing mental illness on a more scientific foundation